The bicoastal bid to shore up Obamacare

The Healthcare.gov website is shown. With the start of Obamacare's fifth enrollment period on Nov. 1, the task for the blue states — California, New York and others running their own exchanges — is to mute, or at least counter, President Donald Trump’s messaging. | Alex Brandon/AP Photo

Two big blue states on opposite sides of the country have a mission: Save Obamacare.

California and New York, which run their own health insurance exchanges and will spend tens of millions this year on marketing and outreach, don’t expect to have a stellar year in the sign-up season that starts Wednesday.

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But both are going all out to keep their marketplaces stable, creating a counter-narrative to the negativity and uncertainty created by the Trump administration from the moment it took office. The two have the biggest state-run exchanges in the country.

“Covered California is going out in a big way for open enrollment this year," said Peter Lee, executive director of the state’s exchange. On Wednesday, Covered California is starting a big advertising push and a 19-city bus tour up and down the state to encourage sign-ups because it’s “more important than ever” to help consumers understand their options, he said.

New York officials sound similar themes.

“When you can’t trust the federal government to protect your constituents, you have no choice but to do it yourself," said New York Mayor Bill de Blasio. "In NYC, we have an entire team dedicated to the cause." The mayor said they've done targeted outreach to 300,000 families already this year, and another push gets underway now that the sign-up season is starting.

It's smart policy, he said: "When more people are covered, that means fewer uninsured people in our emergency rooms, saving our hospitals and our taxpayers money."

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The task for the blue states — California, New York and others running their own exchanges — is to mute, or at least counter, President Donald Trump’s messaging in this fifth enrollment period. The president keeps declaring Obamacare “dead,” which confuses the public. His administration has also truncated the federal sign-up season to six weeks from 12, and slashed outreach and consumer assistance. It’s all part of his efforts to discourage enrollment and discredit the Affordable Care Act.

That becomes a self-fulfilling prophecy. The worse Obamacare performs this year, the easier it is for Republicans to keep depicting it as a failed program that must be scrapped.

That why the two states are so eager to show stable enrollment and significant health plan buy-in. They want to create a success story to bolster the ACA from the Republican assault, which may have shifted form, but has not ceased since repeal efforts failed in Congress.

California and New York spent the past four open enrollment periods establishing their brands. Covered California has about 1.4 million Californians enrolled. New York State of Health has just under 1.3 million covered. Health insurers have largely remained in both exchanges, so there’s a lot more choice and competition than in parts of the country where insurers have fled. New York has 12 insurers offering plans next year — down from 14. California's 11 plans remain in Covered California, although one, Anthem Blue Cross, drastically shrank its footprint for 2018.

While the federal government has cut Obamacare advertising and outreach from $100 million to $10 million this year, California increased spending this year to about $111 million — or more than 10 times what the federal government is paying for in the 42 states that rely on the federal HealthCare.gov site. New York has committed to spending $27 million on advertising and outreach, the same as last year.

"Despite the ongoing debate in Washington over the future of the Affordable Care Act, New York's marketplace remains open and strong as ever," said exchange executive director Donna Frescatore.

Both states also committed early on to keeping the original 12-week enrollment period. They will both run until Jan 31, while the federal exchange sign-up will go from Nov. 1 to Dec. 15. Looking ahead, California even passed a new law establishing that its enrollment period will run from Oct. 15 through Jan. 15 starting in 2019.

New York is expanding its advertising, targeting specific communities, such as Hispanics and people under 35, or putting ads in grocery stores and pharmacies in select areas to remind people that insurance options are available. The state is still offering navigators and in-person assisters for enrollment. New York also benefits from an auto-renewal option, which more than two-thirds of those enrolling in a private health insurance plan have opted for.

California, meanwhile, completed its biggest revamp to its online sign-up process since the site’s inception, and people will be able to sign up on their cellphones this year. It’s also ramping up its advertising campaign, convinced it more than pays for itself by bringing in younger and healthier clients needed to keep premiums lower and make the market work for everyone.

New York has not released any enrollment projections for next year. Covered California officials have been loath to make enrollment projections, and say only that they aim to sign up about 400,000 new enrollees — essentially replacing the estimated churn created each year when consumers drop in and out of the exchange, often because they can now get coverage through a job or a family member. A realistic goal would be to hold steady: “We anticipate having the same number of insured as we come out of open enrollment [next year] as we did in 2017,” Lee said.

Texas could be a case study at the opposite end of the spectrum. At 16.6 percent, Texas has the highest uninsured rate of any state and has fought Obamacare at virtually every turn. It refused to expand Medicaid, relies on the federal government exchange and has taken a hands-off approach to trying to keep insurers in the game.

Even so, more than a million Texans enrolled in its Obamacare marketplace. But given the state’s lack of enthusiasm, it's likely Texas' enrollment figures will fall in the coming year as Washington is no longer pushing sign-up as it did in the Obama administration.

The same can be said of the overall federal market, since the federal government shares that attitude. Joshua Peck, who served as HealthCare.gov's chief marketing officer under President Barack Obama, forecasts that at least 1.1 million fewer people will be covered through the federal exchanges solely due to the cuts in federal advertising. He based his projection on a comparison of how the federal government fared spending 10 times as much in previous enrollment periods with what the current administration plans to spend now.

Ongoing consumer confusion also shadows the law’s future. After a year of failed efforts to repeal and replace Obamacare, Trump in October abruptly cut off the so-called cost-sharing reduction payments, which are the subsidies that cover the co-payments and other out-of-pocket costs for lower-income enrollees who also receive subsidies that help cover their monthly premiums.

Trump’s actions didn’t directly affect those consumers. The tax-credits that reduce consumers' premiums remain intact. And those who are eligible will still get those cost-sharing reduction payments from their insurers, even now that the federal payments have stopped. But those complexities are awfully tough for consumers to follow.

A day after the president cut the payments, a Covered California member wrote on the exchange's Facebook page: "Devastated that our health insurance was just destroyed by an Executive Order!!! Hubby is 6 months off chemo, we are devastated! What do we do now?? YOU guys have been amazing … don't want to lose YOU or our Kaiser coverage."

California and a few other states also put into place a workaround plan after Trump cut off the cost-sharing payments, and also to help those who make too much to money to qualify for financial help. Covered California loaded a surcharge to mid-level silver plans to make up for the lost premiums. That in turn requires the federal government to make up for the lost funding by making bigger subsidy payments for premiums.

California then worked on a remedy for people who don’t qualify for help buying their insurance — and who didn’t want to have to pay that surcharge. The state worked with insurers so that these customers can get a similar health plan outside the exchange, without that extra cost. Ironically, the contingency plan may cause most subsidized Covered California customers to see a slight drop in their premiums — an average of 1.5 percent from 2017 to 2018, or the equivalent decrease of $9 per month or $108 a year.

Whether the states’ efforts during this open enrollment will yield success, only time will tell. But even a state like California, which has been bullish on the ACA since the start, isn't immune to the turmoil on the federal level.

Lee noted that this is not just a red-state versus blue-state conflict, but a divide between those states that are trying to make their marketplaces work and those that aren’t. Idaho, for instance, is a very conservative state, but it’s still running its own exchange.

"We will be able to look at the enrollment in 2018 and see what happens in states like California, Colorado, Washington and Idaho and compare that with states like North Carolina, Tennessee and Georgia and Texas," Lee said. "As much as I would love to be proven wrong, I think the losers in this likely future are the millions of Americans who are likely to not know they could be eligible for affordable coverage and the millions of unsubsidized Americans who are going to be priced out."